What is the appropriate management for a patient with a sore throat lasting 7 days?

Management of 7-Day Sore Throat

For a sore throat persisting 7 days, provide symptomatic relief with ibuprofen or paracetamol, assess severity using clinical criteria (Centor score), and consider antibiotics only if 3-4 Centor criteria are present—but recognize that at 7 days duration, the natural course has nearly completed and antibiotic benefit is minimal. 1

Initial Assessment and Red Flag Evaluation

At 7 days duration, this presentation approaches the upper limit of typical acute pharyngitis, which usually resolves within less than one week in over 80% of cases. 2 Your first priority is excluding serious complications:

• Evaluate for peritonsillar abscess (quinsy), retropharyngeal abscess, or Lemierre syndrome—these require urgent intervention 2
• Look for severe systemic symptoms, immunosuppression, or inability to swallow, which would necessitate immediate referral 3
• Consider non-infectious causes at this duration, including gastroesophageal reflux disease or, though less likely, neoplastic processes 2

Symptomatic Management (First-Line for All Patients)

Recommend either ibuprofen or paracetamol for pain relief regardless of etiology. 1 This remains the cornerstone of treatment and provides meaningful symptom control. 4

• Zinc gluconate is not recommended 1
• Corticosteroids are not routinely recommended, though may be considered in adults with severe presentations (3-4 Centor criteria) in conjunction with antibiotics 1
• Herbal treatments and acupuncture have inconsistent evidence 1

Determining Need for Antibiotics

Use the Centor score to stratify risk (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough): 1, 5

• 0-2 Centor criteria: Do not prescribe antibiotics—these patients have low probability of streptococcal infection and antibiotics provide no meaningful benefit 1
• 3-4 Centor criteria: Consider testing with rapid antigen detection test (RADT) or throat culture, and discuss the modest benefits of antibiotics with the patient 1

Critical caveat at 7 days: Even untreated streptococcal pharyngitis typically shows fever resolving within 3-4 days, with throat soreness lasting at most 1-2 days longer than antibiotic-treated cases. 2 At this point in the illness, antibiotics will provide negligible symptom reduction since the natural course has already exceeded the 1-2 day benefit window. 2

Antibiotic Selection (If Indicated)

If you decide to treat based on positive testing or high clinical probability, prescribe penicillin V 250-500mg twice or three times daily for 10 days. 1 This remains first-line due to proven efficacy, narrow spectrum, low cost, and lack of resistance. 1, 4

• Amoxicillin is an acceptable alternative, particularly in children for palatability 4, 5
• For penicillin allergy: First-generation cephalosporins, clindamycin, clarithromycin, or azithromycin 4
• Avoid shorter courses: Evidence does not support treatment durations less than 10 days, despite some studies showing marginal differences 1

Key Pitfalls to Avoid

• Do not assume this is simple streptococcal pharyngitis and prescribe antibiotics empirically—the 7-day duration makes uncomplicated bacterial pharyngitis less likely 2
• Do not use broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy; this increases resistance and side effects without additional benefit 6
• Do not routinely perform follow-up throat cultures after treatment in asymptomatic patients 4
• Do not dismiss the patient if symptoms persist beyond a few more days—re-evaluation is warranted to assess for complications or alternative diagnoses 4, 2

When to Reconsider the Diagnosis

If symptoms persist beyond 14 days total, this falls outside the definition of acute pharyngitis used in major guidelines, and you should actively pursue alternative diagnoses including chronic infectious causes, reflux disease, or neoplastic processes. 2 Most viral and bacterial pharyngitis resolves well before 2 weeks. 2